When fresh ginseng is processed by steaming and drying it is referred to red ginseng (Ginseng Radix Rubr). Ginseng is also processed by drying and it’s referred to as white ginseng (Ginseng Radix Alba).

Red Ginseng translates to “Hongsam” in Korean and it dates as back as to 1776–1800, when it was mentioned in the Annals of the Joseon Dynasty, specifically the Annals of King Jeongjo. Although the original steaming process of ginseng dates back to 1123 by GoRyeoDoGyeong, only 100 years later Taekyoung Kim writes the specifics of the method. Based on the record, the ginseng roots had to be grown for at least six years prior to washing and steaming them, laying on bamboo racks, and drying by fire heat, sunlight heat in combination with the wind. Later in the modern days, the process has been re-written in 1908 in the Bulletin of Ginseng Policy, Ministry of Strategy and Finance, The Greater Korean Empire; in this record, additional details for the process have been added. These include the classification of ginseng in categories based on size after the washing stage, their placement and sealing in clayware steamers, and the steaming duration contingent on the ginseng size was indicated to be 50-90 minutes. The practice of steaming by size and shape continued to the present day. In addition, because the red ginseng production was “monopolized” by the Japanese colonial government between 1908–1996, the production processes and system have been standardized. Current processes derive from these past standardized practices (2).

TRADITIONAL USES

WHAT DOES SCIENCE TELL US?

Ginseng Might Support Balanced Blood Glucose Levels:

Research literature related to ginseng is dominated by ginseng’s effects on blood glucose. Robust research with repeated double-blind clinical trials indicates moderate consistency in research on ginseng’s potential in decreasing blood glucose. Nine studies, in addition to a systematic review, indicated positive outcomes in the use of ginseng to decrease blood glucose, while two studies did not see any effect (4,5,6,7,8,9,10,11,12,13,14,15). The general supplement dose administered in the studies where ginseng proved to be effective, ranged from 0.08 to 20 g of ginseng/day.

A systematic review which included 22 randomized controlled trials (n=1,115) and 12 non-randomized studies (n=604) examined the effect of ginseng on cardiovascular risk factors (blood pressure and lipid). The review included studies with both healthy subjects as well as subjects with congestive heart failure, hypertension, type 2 diabetes mellitus or mild blood abnormalities, and individuals with physical or mental stress. The subjects were assigned dosages from 0.08 to 7.5 g/day of Panax ginseng, Panax ginseng extract, and American ginseng for the duration of up to 27 months. The lipid results of the studies reviewed (3 randomized controlled trials, 6 non-randomized studies)were inconsistent. The blood glucose results of the single-dose studies reviewed among three acute studies did not find changes in the postprandial blood glucose; out of four randomized controlled trials and two non-randomized studies among the multiple-dose studies, four studies showed a significant decrease in blood glucose measures (in comparison with placebo). This included 7-10% reductions in fasting blood pressure (3 studies), in glycosylated hemoglobin 4-8% (2 studies), and in blood glucose 13% (1 study). The authors disclaimed the possibility of relevant studies that might have been missed (4).

A 12-week randomized, double-blinded, placebo-controlled study evaluated ginseng efficacy in 60 subjects (20-70 years old) with impaired fasting glucose (IFG), impaired glucose tolerance (IGT), or newly diagnosed type 2 diabetes mellitus (T2DM). They were either given 5g of ginseng in tablet form or placebo. Post-measurement of glucose-related biomarkers showed a significant decrease in serum levels of glucose. The study concluded ginseng’ potential in controlling whole blood glucose and serum levels of glucose in subjects with the aforementioned conditions (5).

In a randomized, double-blind, placebo-controlled trial, 42 subjects (with impaired fasting glucose or type 2 diabetes) were divided into two groups and given either ginseng or placebo for a duration of four weeks. Post-assessment of fasting and postprandial glucose profiles showed a significant reduction in postprandial glucose levels and an increase in postprandial insulin levels in the ginseng group. The results did not show a change in the fasting glucose, insulin, and lipid profiles. The study concluded ginseng’ effectiveness in lowering postprandial glucose levels in the studied subject types (with impaired fasting glucose or type 2 diabetes) (6).

A double-blind study investigated the influence of ginseng on exercise-induced muscle damage and inflammation responses by randomly assigning 18 males (18-29 years old) to ginseng and a placebo intake group. The ginseng group received 20 g/day of Korean Ginseng extract for the duration of 7 days prior to the endurance task and 4 days after an additional test. Oral glucose tolerance test was also performed showing improvement in insulin sensitivity, glucose reduction, muscle damage reduction, and hindrance in inflammation response; (p < 0.05) (9).

A double-blind, placebo-controlled study investigated the effects of ginseng in 36 non-insulin-dependent type II diabetic patients for a duration of 8 weeks. They were given 100 or 200 mg of ginseng or placebo. Tests were performed to evaluate the effects including psychological, as well as additional physical measurements were performed including checking the glucose balance, serum lipids, aminoterminal propeptide concentration, and body weight. The results of the study showed a reduction of fasting blood glucose and body weight, in addition to improvement in mood and psychological performance (13).

In two double-blind, placebo-controlled, cross-over studies the effects of ginseng ingestion have been investigated in healthy subjects (17 volunteers in one and 12 volunteers in the second). The results of the studies did not show an effect of ginseng on glucose in subjects (14).

In a double-blind, randomized, controlled study 48 subjects with metabolic syndrome were given 4.5 g/day of ginseng or placebo for 12 weeks. Post collection of anthropometric measurements, blood for laboratory testing, and brachial-ankle pulse wave velocity results of the ginseng group in comparison to the placebo group showed no significant effects on fasting blood glucose, blood pressure, arterial stiffness, lipid profile, and oxidized LDL (low-density lipoprotein) (15).

Ginseng Probably Increases Cognitive Abilities:

Multiple double-blind placebo-controlled clinical trials provided a high consistency in research results on ginseng’s positive effects on cognitive abilities with only one study proving mixed results. Many studies noted this may be due to ginseng’s effect on reducing mental fatigue (11,12,16,17,18,19,20,21,22).

In a double-blind, randomized, placebo-controlled study 15 subjects (healthy young males with no psychiatric or cognitive problems) were given 4,500 mg red ginseng/day or placebo for a duration of two weeks. Post-assessment via the Vienna test system and the P300 event-related potential test showed a decrease in C3 latency (p=0.005) of the ginseng group during the study. Further significant decreases occurred in the ginseng group after the two-week duration in the P300 latencies at Cz (p=0.008), C3 (p=0.005), C4 (p=0.002), and C mean (p=0.003). The study concluded that a larger sample size is necessary with longer follow up periods to determine ginseng’s clinical efficacy (16).

In a randomized study, forty subjects (patients with Alzheimer's disease) were divided into four groups and given 1.5 g/day ginseng, 3 g/day, 4.5 g/day or placebo for a duration of 24 weeks. Post-assessment via the Alzheimer's Disease Assessment Scale and Mini-Mental State Examination showed significant improvement in the ginseng groups, but specifically, 4.5 g/day ginseng group showed improvement in the cognitive and non-cognitive component of Alzheimer's Disease Assessment Scale and in the Mini-Mental State Examination in the 12th week which continued through the 24th week of follow up. The study concluded ginseng’s potential efficacy on behavioral aspects and the cognitive function in the studied subject types (patients with moderately severe Alzheimer's disease) (17).

A systematic review evaluated five out of nine double-blind and single-blind randomized, placebo-controlled trials on healthy subjects; the rest did not include extractable data. Ginseng’s potential in improving cognitive performance was assessed. Four of the five studies specifically examined the effects of ginseng extract, while one of the studies investigated the efficacy of HT008-1 (ginseng’s compound). While the review found ginseng to improve some cognitive functions, aspects of behavior and life quality, it concluded that convincing evidence for the aforementioned outcomes produced by ginseng is lacking and further research with large sample sizes is needed to investigate ginseng’s potential in improving cognition (19).

In a randomized, double-blind study, 200 mg/day was given to 15 subjects and placebo to another 15 subjects for 8 weeks. Post-assessment results of the general health status questionnaire showed higher scores in social functioning (p = 0.014), mental health (p = 0.075), and the mental component summary (p = 0.019) after four weeks of therapy; however, these differences did not continue through the eighth week (20).

In a randomized, double-blind, placebo-controlled study, 90 subjects (21 men, 69 women, with idiopathic chronic fatigue) were given bespoke 20% ethanol extract of ginseng 1 g or 2 g/day (-1)) or a placebo for a duration of 4 weeks. Post-assessment of fatigue monitoring showed a not statistically significant decrease in the self-rating numeric scale, while significant improvement in the mental aspect compared with placebo (p<0.01), a significant reduction in the visual analogue scale score compared with placebo (p<0.01), and 1g of ginseng increased the total glutathione concentration and glutathione reductase activity, concluding ginseng’s ant fatigue effects in the studied subjects type (with idiopathic chronic fatigue) (21).

In a randomized, double-blind, placebo-controlled study, fifty-two subjects (female patients with multiple sclerosis) were divided into two groups and given either 0.5 g/day of ginseng (divided into two portions every day) or placebo for a duration of three months. Post-assessment showed a positive result in the ginseng group as measured by the Modified Fatigue Impact Scale (p = 0.046) and by the Iranian version of the Multiple Sclerosis Quality Of Life Questionnaire (p ≤ 0.0001). The study concluded ginseng’s effectiveness in reducing fatigue and improving the life quality (22).

Ginseng Might Help Support Penile Function:

Ginseng is most likely effective in treating erectile dysfunction and may have a positive effect on treating male infertility. Multiple double-blind, placebo-controlled studies indicate a very high consistency in findings regarding ginseng’s effectiveness in treating erectile dysfunction.

One study also addressed ginseng’s usefulness in treating male infertility. The improvement in erectile dysfunction has been observed with 0.6g to 3g a day of ginseng berry and overall red ginseng (23,24,25,26,27,28,29).

In a double-blind, placebo-controlled, multicenter study, 119 subjects (men with mild-to-moderate erectile dysfunction) were given either 1.4 g/day ginseng berry (in forms of tablets; 350mg ginseng berry extract per tablet) or placebo for a duration of eight weeks. Post-assessment showed an increase of individual domains via the International Index of Erectile Function (P<0.05), the erectile function domain slight change of the International Index of Erectile Function (P<0.05), and a significant improvement in premature ejaculation diagnostic tool scores (P<0.05) in the ginseng group. The study showed ginseng’s efficacy in improving all domains of sexual function (23).

In a systematic review, seven randomized controlled trials were assessed to investigate the effectiveness of red ginseng for the treatment of erectile dysfunction. Men (n=363, 24-70 years old) with erectile dysfunction were given 600 mg to 1000 mg for the duration of four to twelve weeks. Post-assessment via International Index of Erectile Function, Watts sexual function questionnaire, global efficacy question and author-designed questionnaires showed ginseng’s association with significant improvement in the erectile dysfunction subjects (p<0.0001) and psychogenic erectile dysfunction (p=0.001); ginseng was associated with better sexual function in comparison to placebo (p<0.00001). Although the evidence found in the study suggested that red ginseng is effective, the review concluded that more quality randomized controlled trials are needed to confirm these findings (24).

In a double-blind, placebo-controlled study, 60 subjects with mild to moderate erectile dysfunction were given either 1,000 mg (3 times daily; a total of 3 gr) of ginseng or a placebo for 12 weeks. Post-testing via the International Index of Erectile Function, results were significant in the ginseng group (P <0.0001) indicating the ginseng can be effective in treating erectile dysfunction (25).

In a double-blind, placebo-controlled study, 86 subjects with erectile dysfunction were given 1000 mg twice a day (a total of 2 gr/day) and a placebo for 8 weeks. Post analysis via the International Index of Erectile Function (IIEF) questionnaire showed significant improvement on five domains of the analysis (P<0.05), suggesting ginseng’s potential in treating the erectile dysfunction (26).

In a double-blind, placebo-controlled study 90 subjects were given 600 mg twice a day (a total of 1.8 gr/day) ginseng, trazodone antidepressant medication, or placebo for an unclear period of time. Post-treatment results indicated significant changes in early detumescence and erectile parameters (p <0.05). The results showed 60% efficacy of the overall therapeutic efficacies in the ginseng group, 30% for placebo and trazodone groups (28).

Ginseng Possibly Helps Older Women:

There is insufficient evidence on the effect of ginseng on menopause, but the existing evidence suggests that ginseng might improve sexuality in females during menopause. The minor magnitude of effect was observed in ginseng’s ability to decrease symptoms of menopause. In one of the studies, the treatment of sexual function in premenopausal women was only as effective as the placebo. Ginseng has been effective in improving sexual arousal domain in menopausal women when ingested in the amount of 3 gr per day for 2-4 weeks (30,31,32).

In a placebo-controlled, double-blind, and crossover clinical study, 23 subjects (premenopausal women), divided into two groups, were given either 3g/day of ginseng (in form of capsules; 3 capsules with 1 g per capsule) or placebo for a duration of eight weeks (32). A two-washout period followed after which the participants in the two groups were swapped. Post analysis via the Female Sexual Function Index showed an increase in scores (p = 0.015) in the ginseng group and p = 0.003 in the placebo group, with not a significant difference between the treatment group and the placebo (p = 0.702). The study concluded ginseng’s effectiveness in improving sexual desire, arousal, orgasm and satisfaction domains (with no effect compared to placebo) (32).

Ginseng Might Help Reduce Blood Pressure:

The literature on ginseng’s effect on blood pressure is generally inconsistent with robust evidence supporting both the reduction in blood pressure and not yielding significant effects or effects similar to placebo (4,15,33,34,35,36,37).

A systematic review which included 22 randomized controlled trials (n=1,115) and 12 non-randomized studies (n=604) examined the effect of ginseng on cardiovascular risk factors (blood pressure and lipid). The review included studies with both healthy subjects as well as subjects with congestive heart failure, hypertension, type 2 diabetes mellitus or mild blood abnormalities, and individuals with physical or mental stress. The subjects were assigned dosages from 0.08 to 7.5 g/day of Panax ginseng, Panax ginseng extract, and American ginseng for the duration of up to 27 months. The results of the review showed a significant reduction in the blood pressure in comparison with placebo in two randomized controlled trials (in multiple dose studies; 6 randomized controlled trials, 2 non-randomized controlled trials). This included a study in which both, the systolic blood pressure was reduced (4%) in subjects with type 2 diabetes mellitus, and the diastolic blood pressure was reduced (3%) in subjects with physical or emotional stress (both in comparison to placebo). Although not significant, in three studies there were slight blood-pressure elevations (1 to 4%), in which two were in comparison to placebo and the other in comparison to the baseline. Out of all single-dose studies (one randomized control trial and three non-randomized studies), two acute studies (one randomized controlled trial and one non-randomized study) showed a greater decrease in systolic and diastolic blood pressure (8 to 11%) (4).

In a randomized, double-blind, placebo-controlled study, 62 subjects (men with metabolic syndrome) were given either 3g red ginseng/day or a placebo for the duration of four weeks. Post analysis comparing the ginseng group with the placebo group showed significant improvement in mitochondrial function, an increase in total testosterone levels, in IGF-1 levels (insulin-like growth factor 1); (P=0.01) in the ginseng group. In addition, there was a significant decrease in serum cortisol and the diastolic blood pressure in the ginseng group. The study concluded ginseng’s positive effect on both, the mitochondrial function and hormones in the studied subjects type (men with metabolic syndrome) (35).

In a randomized, double-blind, placebo-controlled study, 62 subjects (nonobese, nondiabetic, prehypertensive), divided into two equal groups, were given either 5 g red ginseng/day (a total of 10 capsules) or placebo for a duration of 12 weeks. Post analysis showed a significant reduction in systolic (6.5 mm Hg) and diastolic (5.0 mm Hg) blood pressure in comparison with controls (36).

In a double-blind study ginseng effect on arterial stiffness in 80 subjects with hypertension was evaluated. Volunteers were given 3 g/day or a placebo for 3 months. Post-testing of arterial stiffness via brachial-ankle pulse wave velocity measurement showed improvement in subjects with hypertension for all groups, thus no difference in subjects who were assigned ginseng. Although blood pressure was significantly reduced in the ginseng group, the effect was similar in the placebo group (p<0.05) (33).

Ginseng Possibly Has Antioxidant Properties:

The literature shows that an intake of 1g-6g/day of ginseng (low and high dose) appears to be effective in increasing antioxidant enzymes and oxidative stress markers in healthy subjects and postmenopausal women (38,39,40). When a low dose of 1 g/day of ginseng was tested on hyperlipidemic patients study did not yield significant results (41).

In a randomized, double-blind, placebo-controlled study, 71 subjects (postmenopausal women; 45-60 years-old) were assigned 3g/day of red ginseng or placebo for a duration of twelve weeks. Post-assessment results showed a significant increase (p<0.001) in the serum superoxide dismutase activity (an enzyme that acts as an antioxidant defense) in the ginseng group which was significant in comparison with the placebo group (p=0.004). Although the serum malondialdehyde levels appeared to decrease, in comparison with the placebo group these changes were not significant (p=0.001 and p=0.064 respectively); no changes were noted in the serum glutathione peroxidase and 8-hydroxydeoxyguanosine. Furthermore, the results did not have an effect on insulin resistance, fasting insulin, and fasting glucose. This study also supports ginseng’s ability to potentially reduce oxidative stress through the increase of antioxidant enzyme activity in postmenopausal women (38).

Ginseng Possibly Supports Calmness:

Only one study has been identified on the effect of ginseng on improving calmness; as such, the evidence is inadequate. The evidence that does exist suggests that ginseng in a dose of 200-400 mg is effective in improving calmness in healthy young subjects, albeit, the results are based on subjective ratings (42).

Ginseng Possibly Possess Anti-Depressive Effects:

In a randomized, multicenter, double-blind, parallel group study, 384 postmenopausal women (mean age 53.5 +/- 4.0 years) were given either ginseng or placebo for an unclear duration of time. Post questionnaires analysis of physiological parameters including follicle-stimulating hormone (FSH) and estradiol levels, endometrial thickness, maturity index and vaginal pH, and psychological parameters including Psychological General Well-Being (PGWB) index, Women's Health Questionnaire (WHQ), and Visual Analogue (VA) scales showed improvement for the ginseng group in the following psychological areas: depression, well-being and health subscales (p< 0.05); however, there were no statistically significant results in the physiological parameters. While the menopausal symptoms and the hypothalamic function weren’t improved, there was a slight reduction of depression and improvement in the well-being as evidenced by the p-value (43).

Ginseng Possibly Increases HDC-L Levels:

Limited clinical studies found ginseng’s capability in increasing HDC-L levels in subjects with mild to moderate erectile dysfunction and subjects with metabolic syndrome who were given 3 to 4.5 g a day of red ginseng for a duration of 12 weeks. As such, the evidence is limited, and additional research is necessary to confirm these results in the populations studied.

In a double-blind, randomized, controlled study 48 subjects with metabolic syndrome were given 4.5 g/day of ginseng or placebo for 12 weeks. Post collection of anthropometric measurements, blood for laboratory testing, and brachial-ankle pulse wave velocity results of the ginseng group in comparison to the placebo group showed an increase in HDC-L while no significant effects on fasting blood glucose, blood pressure, arterial stiffness, lipid profile, and oxidized LDL (low-density lipoprotein) (15).

Ginseng Possibly Decreases Inattention/Hyperactivity:

There is a deficit of evidence on the effect of ginseng on inattention and hyperactivity. However, an existing study suggests that ginseng may be a great alternative to treating children with ADHD.

In a double-blind randomized placebo-controlled study, seventy subjects (6-15 years; with ADHD) were divided into two groups and given 2g/day of ginseng for eight weeks. Post-assessment showed that compared to the placebo group, the ginseng group had a significant decrease in inattention/hyperactivity scores (p=0.047) and a significant decrease in the quantitative electroencephalography theta/beta ratio (p=0.001). The study concluded ginseng’s potential to be an effective alternative in treating children with ADHD (44).

Ginseng Possibly Supports a Healthy Respiratory System:

One study has been found ginseng’s potential in protecting against acute respiratory illness. Additional evidence is needed to confirm these positive results.

A randomized, double-blinded, placebo-controlled trial studied ginseng’s effectiveness in preventing acute respiratory illness. The study results showed that out of a hundred subjects in the study, fewer subjects in the ginseng group contracted at least one acute respiratory illness than in the placebo group (P = 0.034). In addition, there was no difference between the groups in the symptom duration (P = 0.475). Also, the ginseng group was reported to have a low tendency in the symptom scores (P = 0.241). The study concluded ginseng’s potential effectiveness in protection against acute respiratory illness and even be effective in potentially decrease the length and the scores of the illness’ symptoms (45).

SAFETY

Ginseng is considered to be safe, tolerable, and free of any untoward toxic effect for human ingestion (34,46,47). Although Panax ginseng has shown to be safe when consumed during pregnancy, caution is recommended during the first trimester and lactation (48). Research recommendations include discontinuation of ginseng intake prior to surgery (49).